Introduction

1Childbirth is a powerful and unique experience for each woman, as well as a physiological process whose practices are culturally determined (Jordan [1978]1993). Emotional well-being has been proven to favour a good birth (Gélis [1984] 1991). To understand what a woman needs and experiences during this phase, it is important to know her culture and social values: her rituals, beliefs, relationships and what makes her feel safe within the space where childbirth takes place (Janssen et al. 2009; Snowden et al. 2011). However, the medicalization of childbirth, along with the role of biomedicine as a main global strategy for reducing maternal and infant mortality, is permeating around the world in cultures that already have their own birthing systems, causing changes and resistance within social groups, in countries such as Guatemala (Cosminsky 2016), Mexico (El Kotni 2018), Tanzania (Strong 2020) or Pakistan (Towghi 2018).

2The Sikka community, an ethnolinguistic group located in the island of Flores, Indonesia, also finds itself attempting to balance its respect for longstanding traditions with the imperatives of global economic growth (Butterworth 2008, 2009; Rebuelta-Cho 2020). This paper studies how international and national pressures to reduce maternal mortality create a tension between local knowledge and biomedicine during childbirth, using different concepts such as reproductive governance (Morgan & Roberts 2012: 243), which can be defined as:

The mechanisms through which different historical configurations of actors—such as state institutions, churches, donor agencies, and non-governmental organizations (NGOs)—use legislative controls, economic inducements, moral injunctions, direct coercion, and ethical incitements to produce, monitor and control reproductive behaviours and practices.

Maternal Mortality in Indonesia

5Every day, approximately 810 women die around the world from preventable causes related to pregnancy and birth, 94% of whom live in low and lower middle-income and non-Western culture countries. This highlights the great inequality in the distribution of global resources and the diversity of contexts (WHO 2019). Between 2000 and 2017, the Global Maternal Mortality Rate (MMR) dropped by about 38% (from 342 maternal deaths per 100,000 live births to 211). However, the global Sustainable Development Goals (SDGs) aim to reach less than 70 per 100,000 by 2030 (2019). As certain biomedical practices are widely regarded as effective in treating complications, women’s access to biomedical professionals is considered a human right: this is the main strategy for reducing the MMR around the world (WHO 2019). Indonesia’s MMR was 272 per 100,000 live births in 2000, and 177 in 2017, or a 35% decrease (2019). This rate, which remains far below the international target, varies a lot between islands in the archipelago.

6From the 1990s, the Indonesian Government has worked intensely to reduce MMR in Indonesia. President Suharto’s mandate (1967-1998), aligned with global strategies, started to increase the number of bidan, phasing out the dukun bayi (national official term for midwives with local knowledge) around the country. The national message, based on Dutch postcolonial assumptions, was that these midwives were “primitive”, “dangerous”, and an obstacle to modernity (Niehof 2014). This Eurocentric vision stated that by having access to a bidan, women would stop seeking the services of a dukun bayi (Stein 2007). However, the dukun bayi are still very present in Indonesia, even when biomedical midwives are available—just as in other countries around the world such as Mexico (El Kotni 2018) and Guatemala (Cosminsky 2016).

7In this regard, the World Health Organization (WHO) now recognizes the support that these local specialists provide to women in their respective cultures, encouraging a collaboration between them and biomedical midwives (Lane & Garrot 2016; Miller & Smith 2017; Sibley et al. 2004). However, after political decentralization was established in 1998, local Indonesian governments were allowed to implement national policies according to local needs: collaboration between midwives are therefore not always prioritized depending on the province. In areas such as Sumbawa (Hildebrand 2012), Java (Niehof 2014), Flores (Nova Nanur et al. 2016) and Sulawesi (Yusriani & Octaviani 2014), this collaborative work is undermined by postcolonial and Eurocentric stigma, and limited by the lack of effort, infrastructure and funds on a local scale. This situation leads to these two categories of specialists being positioned as rivals.

8In other areas of Java (Ambaretnani 2012), Lombok (Iacob 2010) or Sumatra (USAID Kinerja 2015), the relation between bidan and dukun bayi is less tense. They organize regular meetings and admit that their practices are not competing but complementary. Local policies aim to defend the rights of both types of specialists, and to continuously improve their collaborations: as a result, tangible improvements can be observed in women’s reproductive health. This comparison shows that in areas where there is a positive relation between these two categories of specialists, the outcomes are more beneficial than in areas where this is not the case. Researchers therefore recommend to improve this situation.

The Case of the Sikka

9Flores is located in the province of Nusa Tenggara Timur (NTT), which is amongst the country’s poorest provinces and those with the highest maternal mortality rate in the country. According to the AIPMNH’s final report published in 2015 (Australia and Indonesia Partnership for Maternal and Neonatal Health), maternal mortality in NTT has gone from 261 deaths per 100,000 live births in 2009 (186 cases) to 151 deaths per 100,000 in 2014 (109 cases), or a 40% drop. However, this number rose again to reach 178 cases in 2015, dropping again to 160 cases in 2017 (DINAS KESEHATAN 2018). In 2007, 77.1% of deliveries took place at home with the support of a dukun bayi and/or a bidan. However, the Riskesdas (Indonesian Health Research Service) showed that some immediate physical causes of mortality such as exsanguination (61% of cases of maternal mortality), other (28%), infection (8%), high blood pressure (2%) and exhaustion (1%) were less likely to be avoided at home (Revolusi KIA NTT 2009). As a consequence, in 2009, the provincial program for maternity care Revolusi KIA NTT imposed the obligation of giving birth at Primary Health Centres or hospitals with a team of bidan available 24 hours a day (2009).

10Due to its success—maternal mortality dropped by 40% between 2009 and 2014—this policy is still a priority to this day (AIPMNH 2015). However, figures remain far below target. In 2016, 13 women died during childbirth in the Sikka district, making it the second district with the highest maternal mortality in the province (Revolusi KIA NTT 2016). Many deaths occur for reasons that remain to be investigated: some studies point at the lack of resources, geographical issues, gender inequality, and the way in which international policies are implemented in different cultural contexts (Ram & Jolly 1998). The Revolusi KIA NTT programme follows the APN procedure (Asuhan Persalinan Normal, or Normal Delivery Protocol in English), based on the global Safe Motherhood Initiative, whose main objective is to help the mother and her family to feel safe and comfortable during childbirth, and to respect the mother’s wishes, culture and beliefs (Depkes 2004). This protocol understands childbirth as a natural and physiological process, centred on the mother and not on the health personnel (2004).

11This protocol involves addressing the woman in labour by her name; encouraging closeness with the bidan; providing her with emotional support, comfort and security; avoiding any unnecessary interventions; requesting the mother’s permission for any action; respecting and allowing her cultural practices; showing her different pain relief methods and encouraging her to try different delivery positions (Pusdiknakes 2003). This protocol seems to aspire to what Davis-Floyd (2001) calls the humanistic paradigm of birth. It is focused on respecting women, and on providing an environment of cultural safety for biomedical practices—meaning “an environment, which is safe for people; where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience of learning together with dignity, and truly listening” (Williams 1999: 214). However, although most births are delivered at Primary Health Centres and hospitals, health personnel are still concerned about homebirths, claiming that this practise is against the law and that it puts mothers and babies at risk.

Cultural Safety vs. Reality

13The name “Flores” is inherited from the Portuguese colonial period (16^th-17^th centuries) (Ricklefs [1981] 2001). This island of exuberant nature, deep valleys, active volcanoes and wide beaches remains mostly rural and embraces a great deal of cultural diversity, as it is inhabited by different ethnolinguistic groups (Moser 2011). The Sikka district has 315,477 inhabitants according to the 2016 local census, and is located in the east-central part of the island. The community, scattered between different villages, is patrilineal-patrilocal and shares a common origin, language and cultural heritage known as Adat (Lewis 2010). However, due to the strong influence of Portuguese colonization, the Adat tradition lives in syncretism with Catholicism. This cultural heritage transmitted from generation to generation is related to the ilmu warisan (ancestral knowledge), and concentrated in a system of beliefs, practices and rituals divided into three areas: reproductive process, marriage alliance and death (Dasi 2013). The community assigns certain people with perpetuating the Adat. They are known as pewaris budaya (cultural guardians).

14The guardians of the reproductive process are the du’a rawin (healers). There is usually one in every neighbourhood. These rural women are respected in the community, as they have been caring for reproductive health since immemorial times. Access to this status is restricted and can only be inherited by women from certain families. Their knowledge also covers other aspects of health. For a woman to decide to become a du’a rawin is a difficult process that depends on her vocational initiative. As it is a demanding job with a low and variable income, these women usually combine it with other sources of income, just like other rural women: these may include collecting and processing local foods, or sewing traditional sarongs to sell them in local markets. Demand for their services usually comes from women of the same neighbourhood, friends and relatives. However, if their work is particularly noteworthy, their fame may spread to other parts of the district. Their tools and techniques are based on prayer: they include massages with special handmade oils and herbal preparations for oral intake. The du’a rawin say that for these treatments to be effective, it is important that they are provided in an environment of “percaya” (trust).

16However, although certain ancestral practices are still crucial for them during childbirth, local women also strongly acknowledge the expertise of the bidan to deal with any complications. Local women are therefore aligned with the humanistic model of birth that the program Revolusi KIA NTT claims to apply. In this context, why are biomedical personnel concerned about homebirths? A male nurse in charge of detecting malaria in pregnant women says:

It is true that some women live far away and do not find transport, but it may also happen that some women checked that they could have a normal delivery after having already experienced homebirth... They may also be too lazy to move... Many say they had not noticed any pain, and that the baby came soon after. How is this possible? It is very difficult to make the community understand! They say “yes” to everything, but then… I tell you that there are women who, knowing and wanting it, deliberately decide not to come to the Primary Health Centre.

17Hay (1999) uses the concept of causal proximity coined by Inhorn (1994) to delve into the multiple causes that lead to maternal mortality in Indonesia: proximate causes such as bleeding, medial causes such as the lack of infrastructure and/or human factors, and ultimate causes such as issues related to destiny or God. Many deaths from proximate causes are produced by the concatenation of various medial causes such as delay in recognizing risks, pre-existing health issues, transport difficulties and/or inadequate treatment in biomedical centres (Nourse 2015). Hay (1999), who witnessed two maternal deaths during her fieldwork, points out that identifying these causes is crucial to prevent proximate causes. However, as maternal death is a relatively rare event to witness, many medial causes can also be extracted from interviews and observation (Grace 1996; Iskandar et al. 1996; Nourse 2015). The following ethnographical description of Ursula’s and Ori’s childbirths, added to ethnographical vignettes and interviews conducted with rural mothers, du’a rawin and other health personnel, can provide some clues in this regard.

Ursula’s Homebirth

18It has been raining heavily for several days and the power goes out frequently. It’s almost 9:00 a.m. Bidan Yuli from the village of Umauta is in the Primary Health Centre waiting for bidan Indah. She tells me that the husband of one of the 33 pregnant women in Umauta has called to inform her that Ursula has given birth at home this morning. Both bidan want to go and check that everything is alright. The three of us get into the ambulance. Ursula is 24 years old and has given birth to her second daughter. Her due date was expected by the end of the month. Bidan Yuli says that she is a responsible mother, who has done all the checks and attended every monthly appointment. Her husband says she gave birth around 2:30 a.m. and that it was impossible to call because his phone had no signal. Furthermore, he justifies that taking her to the Primary Health Centre was difficult. Their house is very far from the road and getting there was impossible due to the rain and lack of light. The bidan bring up the subject of the rumah tunggu (waiting house) for pregnant women in the Primary Health Centre. Bidan Indah points out that this house is designed for cases like this when the woman lives far away. She admits that this measure does not work, and that people find it uncomfortable to stay there for days. She recognizes that the quality of the rumah tunggu in other subdistricts is much better than the one in Bola.

19As we arrive, we see a group of houses clustered on both sides of the road, while the others are scattered throughout the jungle. The kepala dusun (head of the neighbourhood) receives us, saying that they have been without electricity for a week. A neighbour offers to go find Ursula and bring her. Time passes and we do not see anyone. Bidan Indah suggests that we find Ursula’s house. Two boys guide us. The trail is very bumpy, muddy and slippery. Walking this terrain requires full concentration. After a 15-minute walk, we haven’t seen anyone. We understand the difficulty of the situation. We heard a motorcycle approaching. The driver skilfully navigates the ups and downs of the road and tells us that Ursula is close. They took longer because she almost fainted. The ground is steeper than ever. We see them: four men are carrying her on a plastic chair. Behind her are about twelve people. One of them is very close to Ursula and carries the new-born baby in her sarong. She is Mama Silia, her du’a rawin. She says that Ursula’s husband went to fetch her around 12:00 a.m., when Ursula began to feel pain. She says the placenta has been easily delivered.

20As we approach the ambulance, bidan Indah says that only the closest relatives can fit inside. Ursula, her baby, parents, husband and in-laws get in the vehicle. I sit in the front next to the du’a rawin and introduce myself. I ask her about the bracelet that Ursula is wearing on her right wrist. She says that it is a cloth with blessed leaves to protect her from evil spirits. I explain to her that I am studying Adat and that I am not a health worker. Her face seems to light up. She is 60 years old and sells foods on Geliting market. We both agree to meet another day to talk some more. We arrive at the health centre. Another bidan is waiting for us at the entrance with a wheelchair for Ursula. They take her to the postpartum ward. Once there, bidan Yuli takes care of the baby. She weighs 3.1 kg and is healthy. Bidan Indah instructs Ursula to lie down on one of the stretchers and injects her with serum. When looking for the vein, the bidan removes the bracelet from her wrist. I notice some tension in Ursula’s eyes, as the bidan unties it. The doctor comes in, asking in an accusatory tone why Ursula has given birth at home. The bidan explain the reasons.

21Bidan Indah asks everyone to leave the room to examine Ursula’s vaginal area. Her husband, mother and the du’a rawin remain inside. Another bidan gently asks her permission to explore her. She introduces her hand decisively. Ursula groans. The bidan says she needs some stitches and injects several sticks of local anaesthesia to the area. Without waiting 20 seconds or making sure Ursula is not feeling anything, she starts sewing. The bidan lights the area with a torch. Ursula screams at each stitch. One of her hands is gripping the stretcher. The other hand pulls at her mother’s clothes. The bidan puts the baby’s hat in Ursula’s mouth for her to bite and withstand the pain. Her relatives and Mama Silia exchange compassionate glances. The mother blows on her forehead. The du’a rawin looks at me and whispers: “This is hurting too much.” “Almost there, darling,” says the bidan. After the last scream, Ursula looks at us as if she does not believe it is over. The bidan has been sewing for more than 12 minutes. Suddenly, the electricity returns. The bidan sighs and yells: “At last!” But after a few minutes, everything fades again, and a sigh of resignation fills the room. “You cannot work like this,” says bidan Yuli. Finally, Ursula falls asleep, and her relatives leave. They will stay there for the next three days.

22The next day I visit Ursula. She is looking better. Her daughter is next to her. I sit outside with her mother, husband and the du’a rawin. They are well. I ask about the role of Mama Silia in Ursula’s reproductive process. The women look at each other. “Pendamping” (support her), says the mother. She stays silent, wondering whether to tell me something. “Will the bidan be angry at us?” She finally asks. I ask her what she means. “We were afraid that they would get angry with us if they knew that Mama Silia had helped us during the delivery. We wanted to go to the Primary Health Centre, but it couldn’t happen. Mama Silia has accompanied all of us in the neighbourhood and we trust her; but the bidan says that even her massages are forbidden…”

Ori’s Birth at the General Hospital

23In 2016, this hospital received an average of 250 patients per month, mostly pregnant women with high blood pressure, abortions, post-term pregnancies, premature rupture of the membranes, caesarean sections and women transferred from Primary Health Centres, whose deliveries were risky due to their lack of strength, high blood pressure and/or retention of the placenta. Rural mothers and health workers from the Primary Health Centre consider that the professionals who attend deliveries at the General Hospital get angry easily and want women to give birth quickly because of the stress caused by their high workload. Today all stretchers are occupied. It’s 2:00 p.m. The bidan are organizing the paperwork. Ori, from the Waigete subdistrict, is lying on stretcher number four for a post-term pregnancy. She is 31 and about to give birth to her fifth child. Ori’s husband is waiting outside. I introduce myself to her and the three women who accompany her. Ori’s mother and her husband’s little sister introduce themselves. The third woman takes longer to speak: “I am her du’a rawin and neighbour.”

25It’s 4:00 p.m. Ori’s husband enters the room. Without warning, the bidan comes in and introduces her fingers into Ori’s vagina. She is already 10 cm dilated. The bidan tells the husband to stand on Ori’s right, and her mother on her left. The bidan tells Ori to spread her legs and grab her tibias to push. “It all depends on you,” she says. Ori pushes, the baby’s head almost pops out, but goes back in. The bidan says the contractions are weak and injects more oxytocin into the bottle of serum. She tells Ori not to move her right arm, so the oxytocin can circulate well. The bidan inserts a catheter into Ori without warning. Some urine comes out. The husband’s sister and Mama Grasia are by her side. The bidan asks who they are. The sister introduces herself and introduces Mama Grasia saying that she is “just” Ori’s cousin (she is lying).

26A contraction comes. The bidan places her hands on either side of Ori’s belly and pushes with all her strength. This practice is called the Kristeller manoeuvre. Ori cries, brushing away the tears with her left hand to keep her right hand still. The bidan tells the nurse that when the next contraction comes, she will perform an episiotomy and asks her to clean the vaginal area with disinfectant. Another contraction comes. The bidan cuts. Ori has a diagonal cut in the lower left part of her vaginal area. A lot of blood comes out. The bidan presses the wound with gauze. She tells the nurse to perform the Kristeller manoeuvre at the next contraction to practice. The nurse is prepared: one hand is pressing the wall and the other is pressing Ori’s belly for added force. At the next contraction, the nurse presses with all her strength on Ori’s belly without warning her: “Come on, come on, woman, come on,” she says to her without empathy. Ori pushes, but the baby doesn’t come out, she cries silently. “If you cry, it will not be born,” the bidan says. The resident doctor enters the room and approaches the nurse who is pushing. She says she will try too. At the next contraction, the doctor pushes and says to Ori: “Come on, push hard. If you cry, it will not be born”.

27It’s 5:00 p.m. The baby is born. The du’a rawin draws a cross with her fingers on the forehead of the new mother. The doctor leaves without saying anything to anyone. The bidan cuts the umbilical cord and places the new-born on top of Ori. The bidan injects oxytocin into Ori’s left thigh and pulls the scissors that clamp the cord while massaging her belly. The placenta is born. The bidan check it for tears. She inserts her hand into Ori without warning. Ori screams. There is no tear, but she has to sew the episiotomy. She injects anaesthesia: several shots in the vaginal lips and inside. Ori begs: “Please, Mama bidan, let me know when you are going to start so I can take a deep breath.” Without waiting 20 seconds and without warning her, the bidan cleans the wound vigorously and makes the first stitch. Ori cries. She is sobbing in pain. The bidan says that it will only be a moment. “Give her the baby’s hat, so she can bite it,” she says to Ori’s mother.

28I ask another bidan if this is always the way things are done. She says yes, from her own experience, it hurts a lot. She admits not knowing why it hurts so much if they use anaesthesia. A bidan from the postpartum ward enters the room. She sees Ori crying and exclaims loudly: “Oh, the stitches hurt so much! This is what happens to us women”. The bidan who is sewing cleans the blood from the wound after each stitch. She looks as if she is cleaning stains from a glass, pressing and rubbing the gauze forcefully. Ori asks for a break to drink water, but the bidan carries on. Ori asks louder: “Please wait!” Her relatives exchange glances. The bidan has been sewing for 20 minutes. Ori asks if there is much left, the bidan does not answer and continues sewing. The bidan tells Ori to keep her legs open. She finally gives her a break and Ori drinks water. Without waiting for a few seconds, the bidan resumes sewing. The husband asks why it hurts so much, another bidan replies that it is normal. Ori’s legs tremble. The bidan slaps one of her legs and tells her to keep them open, as the trembling makes her task difficult. It has taken 35 minutes in total. When finished, the bidan leaves the room without saying anything to anyone. I go to Ori and ask how she is. “Delivering the baby hurts. But the stitches… have been the worst”, she replies. Exhausted, she falls asleep.

29I sit with Mama Grasia next to the baby. “Why did you say you were her cousin?” I ask. “They don’t like us coming. They don’t trust us or value us. But if a woman asks me, I come with her”. “Why do you think they don’t like you?” I ask. “I do not know. Before, we used to work well together. I felt respected. But now our paths are different. At monthly maternal appointments, the bidan constantly say to women that they cannot come to us, that we cannot massage them or give them any ramuan (herbal preparations)”. “And are you in high demand?” I continue. “The bidan have many patients and so do we. I tell women to go to them, but the bidan forbid us. Women keep calling us, because they need us too. They need us both, the important thing is that mother and baby are well. The bidan think we do our job wrongly, but when I showed them how I did it, they were impressed.”

30“What do you think of the episiotomy?” I continue. “When I was trained as a dukun terlatih, they said you had to give birth face up. I accepted it, although I recommended to women to do it sitting up or squatting because this way the baby falls naturally. But cutting the jalan lahir (path of birth) is not natural. Imagine, after childbirth they cut and sew you up; it hurts a lot and gives women a lot of problems afterwards! I give them ramuan and apply molan (herbal paste) later if there is a wound.”

Obstetric Violence in Labour Wards

31Through the above descriptions of childbirth, one can picture how some current biomedical practices and routines may be conditioning women’s decisions, leading them to favour homebirths. Although in Ursula’s case the medial cause of the lack of infrastructure was obvious for the bidan and the rest of the biomedical team, the description of the treatment she received once she arrived at the Primary Health Centre, as well as the practices experienced by Ori, reveals other type of medial causes related to inadequate treatment in biomedical centres. Therefore, it is clear that although the provincial program claims to be following a humanistic model of birth, what women experience in delivery rooms is very different. The biomedical personnel are unaware of this reality and its consequences.

32Such practices are described by the term obstetric violence, which was defined for the first time in Venezuela as “the appropriation of women’s body and reproductive processes by health personnel, which manifests itself by a dehumanizing treatment, abuse of medicalization and the pathologization of natural processes, resulting in a loss of their autonomy and ability to decide freely about their bodies and sexuality, negatively impacting their quality of life” (República Bolivariana de Venezuela 2007). This gender-based reality experienced by women around the world concatenates negative outcomes in maternal and neonatal health and violates women’s human rights (Castro 1999; Castro & Erviti 2014; Castro & Savage 2017; d’Oliveira, Diniz & Schraiber 2002; El Kotni 2018; Zacher Dixon 2015, Towghi 2018). For almost 40 years, it has been shown that many biomedical obstetric practices and procedures are applied not on the basis of scientific evidence, but because of their cultural significance (Davis-Floyd 2018).

33At the beginning of the 20^th century, obstetrical knowledge started to shift from the female to the male domain in the majority of European countries and their colonies (Jordan 1997). As Western culture was based on a patriarchal society and aimed to take control over the body and its reproduction, obstetrical education and authority in childbirth became exclusive to men, leaving the role of midwives in a subordinated position and reducing their presence and authority in the field (1997). As biomedicine was originally based on the masculine body, which was much more studied than the female one, physicians determined that women’s bodies showed unpredictable differences compared to men’s: they were considered “defective” and in need of constant—male—manipulation (Davis-Floyd 1992). Obstetric violence, related to what Davis-Floyd (2001) calls the technocratic paradigm of birth, stems from the Cartesian dichotomy of mind vs. body, in a context where institutions are governed by technology, capitalism and patriarchy. Women’s socio-cultural dimensions are regarded as meaningless for the outcomes of the birth. However, women’s voices, experiences and complaints are today becoming stronger and more visible.

34As a consequence, the humanistic paradigm of birth as an intermediate model is gaining popularity around the world, as it aims to combine tested biomedical practices with an atmosphere of cultural safety. Nevertheless, as is the case in the Sikka district, local institutions still practice the old methods of biomedical obstetrics, because knowledge and practices very often need time to evolve and change. Recent studies identify six forms of contemporary obstetric violence: verbal and physical abuse, poor relationship with women, sociocultural discrimination, failure to meet professional standards of care, and the condition of the medical system (Bohren et al. 2015; Castro et al. 2015; Castro & Savage 2017). The descriptions of Ursula’s and Ori’s childbirths, as well as the interviews and observation conducted, reveal the following forms of obstetric violence.

Marginalization of the du’a rawin

35For a pregnant woman, the presence of her du’a rawin in this phase is very important. However, as the cases of Ursula and Ori have shown, families fear the reaction of the bidan if they find out that, in parallel, the pregnant woman has required the services of a du’a rawin. This situation even pushes them to lie about the identity of this specialist inside the delivery room, while at home they are not subjected to such pressure. This reality is both a form of cultural discrimination and a failure to meet the professional standards of care. The mutual cooperation between the bidan and the du´a rawin is clearly unsatisfactory. While the latter admit to collaborating with the medical system by encouraging women to attend biomedical checks and meetings, they feel undervalued and attacked by the official discourses promoted at monthly maternal appointments.

36The local biomedical-obstetric team claim that the du’a rawin’s techniques are sembarang (“random”, “nonsense”) as they have not followed any regulated training. However, during my fieldwork, I was unable to find any professional (including senior officials from the Sikka Health Department) who could prove the danger of such treatments based on studies or known cases. An enlightening fact is that many local bidan secretly rely on the expertise of these specialists in diverse ways, demonstrating the importance of these women within their culture, as well as the complementarity of both knowledges (Rebuelta-Cho 2020). The delegitimization of the du’a rawin, common in places where the role of midwives with local knowledge is strong, is a strategy for the reproductive control of women that seeks to position biomedicine as the only authoritative knowledge (Jordan [1978] 1993). In fact, El Kotni exemplifies how in Mexico this is a form of reproductive governance, which consists in trying to “control the reproductive choices of poor women through the control of the women who take care of them: their midwives” (2019:140).

Genitals Exposed, Supine Pushing Position and Stitches

37The Sikka community understands the body as a social, cultural and symbolic construction (Le Breton [1990]2002), and refers to female and male genitalia as kemaluan (the shame of oneself). Women associate this part of the body with what they call harga diri (a person’s value or self-esteem). Conversations with du’a rawin and local mothers reveal that exposing their kemaluan for a long time while giving birth in medical facilities makes them feel “watched, vulnerable and ashamed” (malu). In her study on infertility in Lombok, Indonesia, Bennett (2017) also finds that this is an important matter for Sasak women. In fact, Sikka women explain that this could be a reason for a woman to give birth at home, where their genitals are not continuously exposed. This perception of a lack of privacy within labour wards reflects a form of cultural discrimination and physical abuse. This type of violence is directly linked to the only pushing position allowed during the expulsive phase: the supine position. This practice is far from the recommendations of the Normal Delivery Protocol that advises to facilitate different positions according to women’s preferences. According to women, the most common position is squatting. This is the position that some women who recently gave birth at home used. They say that “it is more comfortable” than the supine position as “the baby falls naturally”. Gélis (1991: 130) points out that:

The supine position is the worst position for childbirth because it compresses the main abdominal blood vessels, the aorta and the inferior vena cava, as well as the uterus of the pregnant woman, causing foetal suffering, hypertension and haemorrhages […]; while other more vertical positions help the expulsion more. This is why […] the positions used in the past were effective.

38The supine position is promoted by biomedicine because it is linked to the idea that female genitalia must be easily accessible and visible in order to work properly (Gélis 1991). However, various studies show that this position contributes to longer deliveries and to the use of chemicals and technology. Women are made to push against rather than along with the perineum, favouring tears and artificial cuts such as episiotomy (Murphy-Lawless 1998). Despite the global biomedical pressure, in different parts of the world such as Guatemala (Cosminsky 2016), or Indonesia in this case, women usually prefer vertical positions. However, one of the bidan admits:

I know the Normal Delivery Protocol says so, but they don’t teach us any other positions than this [supine position] in our training. I don’t want to try them because I don’t know them. In addition, I think that this way would be more difficult for me to see well what is happening and everything would get dirtier.

39Similarly, some mothers miss the traditional rope they can pull at during contractions. At home, the labouring woman usually put herself in a squatting position and grabs a rope hanging from the ceiling. At biomedical centres, women report that they feel uncomfortable as they only have a stretcher. Another source of suffering comes from the stitches. Women associate homebirth with the possibility of avoiding this part, as most of them did not need stitches even after having been explored by the bidan. The observation of childbirths and women’s testimonies show that the period of time during which the bidan sews them is a phase of “unbearable” pain for women. Le Breton ([1995] 1999) argues that although pain is a physiological reaction, its experience is highly connected to sociocultural and individual variations. These narratives of pain communicate the experiences of women through their verbal and body language, and are also a way of externalizing their suffering, fear and frustration (Molina-Serra 2018). These complaints shed light on the links between them and society, and the manifestation of their physical pain reflects their rejection of certain aspects of the social reality they are experiencing (Kleinman 1988).

40The fact that these women identify their genitalia with their harga diri also influences the expression of this pain, which is also experienced by local bidan when giving birth. Stitching is usually performed without any consideration for the new mother, ignoring her pain and requests. This is a source of tensions between the bidan and the families. A questionable matter is the way in which the bidan apply anaesthesia. Some women think that sometimes the bidan do not use it because it is an “expensive” medicine. Although the bidan say it is not, they are aware that they apply it intuitively. In the Primary Health Centre and General Hospital, the bidan inject anaesthesia around the tear without waiting for more than a few seconds for it to be effective, or checking if it has taken effect on the woman in labour. This way of proceeding is also confirmed by a doctor from Jakarta, who works in the Waigete subdistrict:

I see it: most bidan do not use anaesthesia when they consider the tear is superficial [...]. Also, in theory, after applying it, they should wait several minutes and ask the mother if she feels anything before starting to sew. If it was my wife being sewn, they would hear me. I think it has to do with not knowing how to use it, they don’t have that training […]. But women here don’t complain as much as in Jakarta [capital of Indonesia], where patients demand a good service.

41This fact is an invitation to see the experience of pain during sewing stitches as an expression of individual discomfort, as well as a real protest from the female collective (Ware & Kleinman 1992). This situation alerts us to a form of obstetric violence manifested in physical abuse, cultural discrimination, and non-compliance with professional standards or with the conditions of the biomedical system.

Episiotomies, Kristeller Manoeuvre, Pelvic Exams and Umbilical Cord Cutting

42Unlike at the Bola Primary Health Centre, where pelvic examinations are notified beforehand and the Kristeller manoeuvre and episiotomies are not performed because the protocol says so, Ori’s delivery reveals that in the hospital, these practices are carried out in a systematic way, without notifying the woman in labour or explaining her why. These practices, together with the discouraging phrases that the bidan repeat to women, are forms of physical and verbal abuse. The episiotomy (intentional cut performed in the perineum to increase the vaginal opening) is on numerous occasions a practice linked to the supine position (Fernández del Castillo 2006). Despite the fact that deliveries at the hospital are categorized as “high-risk deliveries”, when the bidan are asked why they perform an episiotomy, their reasons do not refer to any scientific evidence. Medical personnel at other centres often say that these bidan do it “so that babies are born faster, and they do not have to wait.” A bidan at the hospital says:

We do them [episiotomies] so that “it” [the genital area] looks nice, because with a clean cut it looks better […]. If “it” does not remain sempurna (perfect), the husband can look for another woman. You can see a lot of difference between the women who have been sewn and those who have not [...]. We know the stitches hurt a lot, but we women hold out and that’s it, that’s how it goes, right?

43However, not one mother expressed any concerns about her vaginal aesthetics. No woman, with the exception of some bidan, referred to di gunting (getting cut) as a positive. Women rather say the opposite, as this represents a direct attack on their harga diri. Mama Grasia and the other du’a rawin interviewed stated that they never cut the “path of birth”. The WHO established that episiotomy is recommended in very few cases, as it shows more drawbacks than benefits: postpartum bleeding and infection, anal tear, incontinence and pain (Fernández del Castillo 2006). For this reason, there is even a reflection on the abusive practice of episiotomy (when performed without any justification) as a form of female genital mutilation (Hartmann et al. 2005).

44Another practice that is performed without consent is the Kristeller manoeuvre. This procedure consists in putting pressure on the uterus so that the baby comes out earlier (Becerra-Chauca 2019). The WHO warns that there is no evidence of its effectiveness and that its application has negative physical and emotional consequences (2015, 2019). Ori’s tears revealed her suffering. Her body went from one specialist to the next, who all told tell her: “If you cry, your baby will not be born.” The du’a rawin are aware that the way you talk to a woman in labour is very important. In their opinion, the bidan do a crucial job in reducing maternal mortality, working in places with obat (medicines) and equipment they do not have. However, they argue that certain local practices should be reconsidered, such as the way in which the bidan treat women in labour sometimes, as well as not cutting the umbilical cord immediately.

45Most mammals do not cut or bite the umbilical cord until the placenta is born (Dunn 2003). However, in humans this varies according to cultures (Coffey & Brown 2017). Although at health centres the cord is systematically cut as soon as the baby comes out, the du’a rawin say that they do not do it until the placenta has been delivered. They argue that this is good for the birth of the placenta and for the baby’s health. Culturally, once the placenta is out, the placenta and the baby lie down like two siblings next to their mother for a while. Then, they proceed to cut that bond, with prayers that honour the help brought by the placenta during the past months. Other studies point out that some cultures in Guatemala and France also had this practice (Cosmisnky 2018, Gélis 1991). In fact, numerous studies confirm that waiting for the cord to stop pulsating before cutting it is beneficial to maximize the amount of oxygen and iron that the placenta passes on to the baby (Rabe et al. 2008, Raju & Singhal 2012). For this reason, the WHO recommends waiting at least one minute to cut it, especially in low-income countries where babies are born with deficient iron levels due to their mothers’ anaemia (WHO 2019). Consequently, in the case of the Sikka district where iron levels are low and maternal and neonatal mortality is high, the immediate cutting of the cord can be considered life-threatening, as well as a cultural discrimination and physical abuse to the mother and baby.

Consequence: Adaptative Preference vs. Personal Empowerment

46The discourses and laws against the du’a rawin generate a lack of transparency and trust between local women and biomedical teams. This pushes women to use secrecy as a tool to perpetuate ancestral practices. This is a consequence of women not being able to freely express their needs and perceptions. Although most mothers admit that the treatment in the Primary Health Centre or hospital is baik (good), their discourse comes with several “buts”: “I wish I could have brought my du’a rawin”, “the pain from the stitches was unbearable”, “as there are too many people... the bidan are not so careful; they are stressed and angry”, etc. These assessments are usually expressed with subtlety, avoiding unpolite words despite the different forms of obstetric violence described above. Castro & Savage (2018) argue that these generous ratings are common around the world, as a result of the very low expectations that women have from biomedical treatment. This means that women do not perceive that they are being exposed to a form of violence (Castro & Erviti 2003).

47In their study on women in the Dominican Republic, Castro & Savage (2018) revealed that women and their families only confront and question health personnel when they feel that their lives and/or those of their babies are in danger. Similarly, bidan Yuli narrated how certain encounters with families from the village of Umauta because of the death of a baby, caused the anger of the community towards the Primary Health Centre. However, usually, women and their families do not complain directly to health personnel, as suggested by the doctor in Waigete: “Women here do not complain like they do in Jakarta, where patients demand a good service.” This acceptance of the service they receive can be related to adaptive preference (Castro & Savage 2018). This concept explains that people tend to endure abuse when they find themselves in environments with structurally restricted options (Terlazzo 2016). In this sense, women’s acceptance is conditioned by the generalized view that biomedical procedures cannot be changed, assuming, as a bidan expressed: “This is what happens to us women”.

48However, although women who had homebirths did not clearly admit that they had planned it in advance, they all revealed the advantages of homebirth such as avoiding stitches, not showing their genitals, and giving birth in a squatting position with just a few people supporting them, among which a du’a rawin. The present study thus proposes that while some women accept the treatment they receive in biomedical facilities, others seek the opportunity to empower themselves and give birth in environments of cultural safety. However, as explained by an interviewee, the possibility of having a homebirth becomes impossible when the mother lives near the health centre:

Sometimes the treatment in the Primary Health Centre is not good, we do not like it. They sew us without using obat (medicines), that hurts a lot! When I went into labour, they checked me up and told me to go home. When I came back, they told me to go again. I was so tired and in pain. The first thing I thought was: “Bah! I might as well give birth at home”. It’s the first thing I thought. But the second thing was to wonder how I was going to do it if I lived so close to the Primary Health Centre, they would be angry. The good thing about giving birth at home is that there are not too many people. In the Primary Health Centre, there are too many. We are ashamed that everyone sees “it” [genitals]. At home they do not.

49Giving such a frank confession requires real trust from the person. This reveals that rural mothers can be critical of the treatment they receive, although they do not complain to the biomedical team, who do not ask for their feedback in any case. This shows that women perceive that they have very few alternatives to give birth in other places than medical facilities, as this is prohibited and sanctioned. As a result, to avoid confrontation, most women accept the appropriation of their bodies, conditioned by the consequences of their not accepting to do it.

Conclusion

50Since the independence of the country in 1945, Indonesian governments have tried to foster nationalist sentiment throughout the country. For this purpose, the “Pancasila” State philosophy, whose motto is “Union in diversity”, has insisted on a selective form of diversity, promoting ethnic particularities such as art, clothing and cuisine, but invisibilizing other deeply rooted particularities such as local medicine, which is considered “primitive” and is expected to be replaced by biomedicine in line with global goals (Hahn 1999). Although this situation may vary depending on the local context due to the introduction of political decentralization, the biomedical sector’ continual attempts at replacing local obstetric practices can be seen as a form of medical colonization (Hildebrand 2017). This process implies different micro-colonization strategies in everyday local life, such as the use of narratives about development and good citizenship (Butt & Munro 2007).

51In the case of the Sikka community, this is reflected in discourses rejecting the du’a rawin and their local practices, forcing all women to give birth in medical facilities according to medicalized birth-giving methods, without allowing any room for local knowledge. This does not take into account rural mothers’ needs, because of prejudices associated with the idea that rural mothers are poorly educated. However, the fact that the bidan themselves and other local workers resort to such traditional treatments in secret shows that: 1. Prejudices towards the du’a rawin have a Eurocentric basis, 2. The services of the bidan and du’a rawin are complementary, 3. Sikka women follow these practices out of trust and reciprocity towards their ancestors, 4. The community wants to maintain such treatments as part of Adat, 5. Because they are afraid to express it publicly, they use local knowledge in secret as a method of resistance.

52The medicalization of birth in the district is thus bringing precipitous changes in local birth-giving practices, particularly since the prohibition of homebirth in 2009, a measure that has now become a priority given its success in reducing maternal mortality. However, homebirths are still a concern for biomedical professionals. This has to do with the fact that although women seek a humane model of birth, they encounter various forms of obstetric violence in labour wards. It would therefore be crucial for biomedical teams to address this issue. These women’s complaints are considered globally as an indication of the dehumanized and abusive treatment they are subjected to. By making this observation, the present article does not intend to point to individual people who do their work the best they can. The purpose is rather to make obstetric violence visible as a form of structural institutional violence, which perpetuates social and gender inequity, as well as hierarchies of power in medical facilities infringing women’s right to have access to respectful healthcare (Bohren et al. 2015; Bowser & Hill 2010; Castro & Erviti 2003; Castro & Savage 2018; Freedman & Kruk 2014; Herrera-Vacaflor 2016; Sadler et al. 2016; Smith-Oka 2013). In the Sikka district, this would require better communication, as well as trust and respect between rural mothers, the du’a rawin, the bidan and the other biomedical personnel. This would also require the eradication of systematic practices such as episiotomy, the Kristeller manoeuvre, unconsented pelvic exams, the prolonged exposure of genitals, the imposition of the supine position, painful stitching and the rejection of local practices such as the free support of a du’a rawin, a rope to pull during contractions and waiting a few minutes before cutting the umbilical cord.